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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530118
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:38:41 PM

Document Has Been Signed on 09/21/2023 02:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MULBERRY MANORFACILITY NUMBER:
365530118
ADMINISTRATOR:CASTANEDA, ERIKAFACILITY TYPE:
740
ADDRESS:1013 N MULBERRY AVETELEPHONE:
(909) 421-4427
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 5CENSUS: 1DATE:
09/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Erika Castaneda, AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Mulberry Manor Residential Care Facility for the Elderly for a scheduled Pre-Licensing Visit. The purpose of this Pre-Licensing Visit is for a Change of Ownership. LPA introduced self and stated purpose of the visit. LPA was greeted and granted entry by Erika Castaneda. LPA signed in as requested, then provided a space to work.

Application: The application is for a Residential Facility for the Elderly - 4/3/23. The fire clearance has been granted for four (4) ambulatory residents and 1 non-ambulatory resident on 5/24/23.

Facility is comprised of 4 bedrooms, 2 bathrooms, kitchen, living room, den, dining room, attached garage and backyard. The facility maintains vendorship with Inland Regional Center. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature - 78 degrees. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were operating appropriately. Hygiene supplies are kept under the sink. LPA tested the temperature from the kitchen faucet, which read at 105 to 110 degrees F. The facility is equipped with operational combination smoke detectors and carbon monoxide alarms. Posters such as; the personal rights and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible through out the facility. There was a designated storage space for client/staff files in the den area. Files are maintained in a secure file cabinet. Medications were locked and inaccessible to residents also. The facility had emergency and first aid kits readily available for residents in

Please see LIC9099C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MULBERRY MANOR
FACILITY NUMBER: 365530118
VISIT DATE: 09/21/2023
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care. Overall, the facility is clean, orderly, in good repair, and operating in safe conditions for residents in care.
Food Service: Non-perishable and perishable food supply is sufficient for number of clients residing in the facility. Food Menus are posted on the refrigerator on a weekly basis. LPA observed that the menu offers oatmeal, scrambled eggs, fried chicken, fruits and vegetables. Dishes, cups, and utensils were stored properly. Emergency food and water were also observed in the attached garage.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. There is 1 staff member who resides in the facility.
Record Review: LPA reviewed 3 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 5 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. The facility last conducted a disaster drills 9/10/23

No deficiencies observed during inspection. LPA will inform the Centralized Applications Bureau the residence is ready to be licensed. An exit interview was conducted. This report was reviewed, discussed then provided to Erika Castaneda.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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